Based On Your Possible Final Diagnosis, What Are The Treatment Plans For Our Patient?
Based On Your Possible Final Diagnosis, What Are The Treatment Plans For Our Patient?
Based On Your Possible Final Diagnosis, What Are The Treatment Plans For Our Patient?
Based on your
possible final
diagnosis, what are
z the treatment plans
for our patient?
PIANO, Alona
PILIEN, Lea Nadine
PLETE, Apollo
PILONES, Matthew
POSADAS, Adrian
z Possible final diagnosis:
How? Why?
z
History ROS
z
• Easy fatigability • Nausea
• Difficulty of breathing • Fever
• Oliguria with occasional dysuria • Blurred vision
• Shortness of breath + orthopnea • Dry cough
• Bipedal edema • Weight change
• Sometimes with puffy face and
abdominal enlargement
TREATMENT
• Intermittent treatment—usually 3–5 hours, three times weekly.
• Treatments may be given in a kidney center, a satellite unit, or the
home.
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z Hemodialysis
Three essential components to hemodialysis:
- dialyzer ,
- the composition and delivery of the dialysate
- blood delivery system
A. Dialyzer
- plastic chamber with the ability to perfuse blood and dialysate
compartments simultaneously at very high flow rates.
- composed of bundles of capillary tubes through which blood
circulates while dialysate travels on the outside of the fiber bundle.
z Hemodialysis
B. Dialysate
3 Types:
1. Fistula
2. Graft
3. Catheter
DIALYSIS ACCESS
-When grafts (or fistulas) fail, catheter-guided angioplasty can be used to dilate
stenoses; monitoring of venous pressures on dialysis and of access flow, although
not routinely performed, may assist in the early recognition of impending vascular
access failure.
DIALYSIS ACCESS
-These catheters are tunneled under the skin; the tunnel reduces
bacterial translocation from the skin, resulting in a lower infection rate
than with nontunneled temporary catheters. Most tunneled catheters
are placed in the internal jugular veins; the external jugular, femoral,
and subclavian veins may also be used.
z Complications during
Hemodialysis
Hypotension
Muscle cramps
Anaphylactoid reactions
z Peritoneal Dialysis
combination of both
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Types of peritoneal dialysis
For some patients in whom CCPD does not provide sufficient solute
clearance, a hybrid approach can be adopted where one or more
daytime exchanges are added to the CCPD regimen.
z Peritoneal dialysis
solutions
volumes typically ranging from 1.5 to 3 L.
Peritonitis
Catheter Associated Non-Peritonitis
Infections
Weight gain
Metabolic disturbances
z Chronic Peritoneal Dialysis
Clear indications for CKD patients include uremic pericarditis, encephalopathy, intractable
muscle cramping, anorexia, and nausea not attributable to reversible causes such as peptic
ulcer disease, evidence of malnutrition and fluid and electrolyte abnormalities, principally
hyperkalemia or ECFV overload, that are refractory to other measures.
Most patients with end-stage renal disease (ESRD)
Temporary relief of symptoms and signs of impending uremia, such as anorexia, nausea,
vomiting, lassitude and pruritus, may sometimes be achieved with protein restriction.
After immunosuppression techniques and genetic matching were developed, renal
homotransplantations became an acceptable alternative to maintenance hemodialysis.
o Renal Transplantation
Results are best with living-related transplantation, in part because of optimized
tissue matching and in part because waiting time and ischemic time can be
minimized; ideally, these pts are transplanted prior to the onset of symptomatic
uremia or indications for dialysis.
Transplant centers now also perform living-unrelated donor (e.g., spousal)
transplants, often in “chains” involving multiple donors to optimize tissue
matching.
Graft survival in these cases is far superior to that observed with deceased donor
transplants, although less favorable than with living-related transplants.
In an attempt to increase utilization of deceased-donor kidneys and reduce
discard rates of organs, criteria for the use of so-called expanded criteria donor
(ECD) kidneys and kidneys from donors after cardiac death (DCD) have been
developed. ECD kidneys are usually used for older pts who are expected to fare
less well on dialysis.
Pretransplant blood transfusion should be avoided, so as to reduce the
likelihood of sensitization to incompatible HLA antigens; if transfusion is
necessary, leukocyte-reduced irradiated blood is preferred.
Overall, the current standard of care is that the pt should have >5 years of life
expectancy to be eligible for a renal transplant, since the benefits of transplantation
are only realized after a perioperative period in which the mortality rate is higher than
in comparable pts on dialysis.
Rejection
Immunologic rejection is the major hazard to the short-term success of renal
transplantation. Rejection may be (1) hyperacute (immediate graft dysfunction due
to presensitization) or (2) acute (sudden change in renal function occurring within
weeks to months).
Usually detected by a rise in serum creatinine but may also lead to hypertension,
fever, reduced urine output, and occasionally graft tenderness. A percutaneous
renal transplant biopsy confirms the diagnosis.
Treatment usually consists of a “pulse” of methylprednisolone (500–1000 mg/d for
3 days). In refractory or particularly severe cases, 7–10 days of a monoclonal
antibody directed at human T lymphocytes may be given.
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IMMUNOSUPPRESIVE
TREATMENT
z I. INDUCTION THERAPY
A. DEPLETING AGENTS
Peripheral human lymphocytes, thymocytes or lymphocytes from
spleens or thoracic duct fistulas are injected into horses, rabbits, or
goats to produce antilymphocyte serum, from which the globulin
fraction is then separated, resulting in antithymocyte globulin.
Polyclonal antibodies induce lymphocyte depletion and the immune
system may take several months to recover.
Monoclonal antibodies against defined lymphocyte subsets offer a
more precise and standardized form of therapy.
Alemtuzumab - directed to the CD52 protein, widely distributed on
immune cells such as B and T cells, natural killer cells,
macrophages, and some granulocytes.
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B. NONDEPLETING AGENTS
Target the 55-kDa alpha chain of the IL-2 receptor, which is
expressed only on T cells that have been recently activated.
Used as prophylaxis for acute rejection in the immediate
posttransplant period and is effective at decreasing the early acute
rejection rate with few adverse effects
z II. MAINTENANCE THERAPY
A. ANITIMETABOLITES
1. Azathioprine
- an analogue of mercaptopurine
- inhibit synthesis of DNA, RNA, or both
- is administered in doses of 1.5-2 mg/kg/day
- reduction in dose is required because of leukopenia and
occasionally thrombocytopenia.
- excessive amounts may cause jaundice, anemia,
and alopecia
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B. STEROIDS
Major effect: preventing the release of IL-6 and IL-1 by monocytes-macrophages
1. Glucocorticoids
- important adjuncts to immunosuppressive therapy.
a. Predinisone
-has effects that are easiest to assess
- effective for the reversal of rejection (large doses)
- 200-300 mg predinisone is given immediately before or at the time of
transplantation, and the dose is reduced to 30 mg within a week.
- maintenance of 5-10 mg/d dose is used for patients whose renal function
is stable after 6mos or a year.
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B. STEROIDS
1. Glucocorticoids
b. Methylprednisolone
- for treatment of acute rejection
- 0.5-1 g IV, is administered immediately upon
diagnosis of beginning rejection and continued once daily for 3
days.
- “pulse” doses are not effective in chronic rejection
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C. Calcineurin inhibitors
1. Cyclosporine
- a fungal peptide with potent immunosuppresive activity
- acts on the calcineurin pathway to block transcription of mRNA for
IL-2 and other proinflammatory cytokines, thereby inhibiting T
cell proliferation.
- more effective in conjunction with glucocorticoids and
mycophenolate.
C. Calcineurin inhibitors
2. Tacrolimus
-previously called FK506
- fungal macrolide that has the same mode of action as
cyclosporine as well as similar side effect profile
- does not produce hirsutism or gingival hyperplasia
- De novo diabetes mellitus is more common with tacrolimus
- first used in liver transplantation
- may substitute for cyclosporine entirely or as an alternative in
renal patients whose rejections are poorly controlled by
cyclosporine
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D. Belatacept
Acute tubular necrosis (ATN) due to ischemia may cause immediate oliguria or
may follow an initial short period of graft function.
Recovery usually occurs within 3 weeks, although periods as long as 6 weeks
have been reported.
Superimposition of rejection on ATN is common, and the differential diagnosis may
be difficult without a graft biopsy.
Cyclosporine therapy prolongs ATN, and some patients diurese until the dose is
reduced drastically.
Many centers avoid starting cyclosporine for the first several days, using
antilympocyte globulin (ALG) or a monoclonal antibody along with mycophenolic
acid and predinisone until renal function is established.
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References